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Chest Pain / Angina Pectoris: Difference between revisions
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In 1772 physician William Heberden first described angina pectoris, writing: “''They who are afflicted with it are seized, while they are walking (more especially if it be up hill), with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life if it were to increase or to continue, but the moment the patient stands still all this uneasiness vanishes''”. | In 1772 physician William Heberden first described angina pectoris, writing: “''They who are afflicted with it are seized, while they are walking (more especially if it be up hill), with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life if it were to increase or to continue, but the moment the patient stands still all this uneasiness vanishes''”. <Cite>REFNAME1</Cite> | ||
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A complete history and physical examination are essential to support the diagnosis (stable) angina pectoris and to exclude other (acute) causes of chest pain such as an acute coronary syndrome, aortic dissection, arrhythmias, pulmonary embolism, (tension) pneumothorax or pneumonia, gastroesophageal reflux or spams, hyperventilation or musculoskeletal pain. | A complete history and physical examination are essential to support the diagnosis (stable) angina pectoris and to exclude other (acute) causes of chest pain such as an acute coronary syndrome, aortic dissection, arrhythmias, pulmonary embolism, (tension) pneumothorax or pneumonia, gastroesophageal reflux or spams, hyperventilation or musculoskeletal pain. <Cite>REFNAME2</Cite> In addition, laboratory tests and specific cardiac investigations are often necessary. | ||
== History == | == History == | ||
Patients often describe angina pectoris as pressure, tightness, or heaviness located centrally in the chest, and sometimes as strangling, constricting, or burning. The pain often radiates elsewhere in the upper body, mainly arms, jaw and/or back. | Patients often describe angina pectoris as pressure, tightness, or heaviness located centrally in the chest, and sometimes as strangling, constricting, or burning. The pain often radiates elsewhere in the upper body, mainly arms, jaw and/or back. <Cite>REFNAME3</Cite> Some patients only complain about abdominal pain so the presentation can be a specific. <Cite>REFNAME4</Cite>, <Cite>REFNAME5</Cite> | ||
Angina pectoris however has some characteristics that can help to differentiate between other causes of (chest) pain. Angina pectoris is usually is brief and gradual in onset and offset, with the intensity increasing and decreasing over several minutes. The pain does not change with respiration or position. If patients had angina pectoris previously they are often able to recognize the pain immediately. | Angina pectoris however has some characteristics that can help to differentiate between other causes of (chest) pain. Angina pectoris is usually is brief and gradual in onset and offset, with the intensity increasing and decreasing over several minutes. The pain does not change with respiration or position. If patients had angina pectoris previously they are often able to recognize the pain immediately. <Cite>REFNAME6</Cite> | ||
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Another way to relieve pain is by administration of nitro-glycerine spray. Nitro-glycerine spray is a vasodilator which reduces venous return to the heart and therefore decreases the workload and therefore oxygen demand. It also vasodilates the coronary arteries and increases coronary blood flow. | Another way to relieve pain is by administration of nitro-glycerine spray. Nitro-glycerine spray is a vasodilator which reduces venous return to the heart and therefore decreases the workload and therefore oxygen demand. It also vasodilates the coronary arteries and increases coronary blood flow. <Cite>REFNAME7</Cite> The response to nitro-glycerine is however not specific for angina pectoris, a similar response may be seen with oesophageal spasm or other gastrointestinal problems because nitro-glycerine also relaxes smooth muscle. <Cite>REFNAME8</Cite> | ||
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During angina pectoris so called vegetative symptoms can occur, including sweating, nausea, paleface, anxiety and agitation. This is probably caused by the autonomic nerve system being more active in a reaction to stress. | During angina pectoris so called vegetative symptoms can occur, including sweating, nausea, paleface, anxiety and agitation. This is probably caused by the autonomic nerve system being more active in a reaction to stress. <Cite>REFNAME9</Cite> | ||
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== Electrocardiogram (ECG) == | == Electrocardiogram (ECG) == | ||
The electrocardiogram (ECG) is an easy and important tool to differentiate between unstable angina (acute coronary syndrome) and stable angina. Patients with unstable angina pectoris are likely to show abnormalities on the ECG at rest, in particular ST-segment deviations. | The electrocardiogram (ECG) is an easy and important tool to differentiate between unstable angina (acute coronary syndrome) and stable angina. Patients with unstable angina pectoris are likely to show abnormalities on the ECG at rest, in particular ST-segment deviations. | ||
Although a resting ECG may show signs of coronary artery disease such as pathological Q-waves indicating a previous MI or other abnormalities, most patients with stable angina pectoris often have a completely normal ECG at rest. Therefore exercise ECG testing might be necessary to show signs of myocardial ischemia. | Although a resting ECG may show signs of coronary artery disease such as pathological Q-waves indicating a previous MI or other abnormalities, most patients with stable angina pectoris often have a completely normal ECG at rest. Therefore exercise ECG testing might be necessary to show signs of myocardial ischemia. <Cite>REFNAME10</Cite> | ||
'''Exercise ECG testing''' is performed with gradually increasing intensity on a treadmill or a bicycle ergo meter. Exercise increases the oxygen demand of the heart, potentially revealing myocardial ischemia by the occurrence of ST-segment depression on the ECG. | '''Exercise ECG testing''' is performed with gradually increasing intensity on a treadmill or a bicycle ergo meter. Exercise increases the oxygen demand of the heart, potentially revealing myocardial ischemia by the occurrence of ST-segment depression on the ECG. <Cite>REFNAME11</Cite> | ||
== Laboratory Testing == | == Laboratory Testing == | ||
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[[File:Figure_1_-_algorithm_for_the_initial_evaluation_of_patients_with_clinical_symptoms_of_angina.png|thumb|right|Figure 1. Algorithm for the initial evaluation of patients with clinical symptoms of angina]] | [[File:Figure_1_-_algorithm_for_the_initial_evaluation_of_patients_with_clinical_symptoms_of_angina.png|thumb|right|Figure 1. Algorithm for the initial evaluation of patients with clinical symptoms of angina]] | ||
Some patients might be unable to perform physical exercise. Furthermore, in patients with resting ECG abnormalities, it might be difficult to interpret the exercise ECG. Finally, if the ECG made during exercise testing does not show any abnormalities angina pectoris becomes very unlikely. However, if the diagnosis is still in doubt, the following additional research may be performed. | Some patients might be unable to perform physical exercise. Furthermore, in patients with resting ECG abnormalities, it might be difficult to interpret the exercise ECG. Finally, if the ECG made during exercise testing does not show any abnormalities angina pectoris becomes very unlikely. However, if the diagnosis is still in doubt, the following additional research may be performed. | ||
# Exercise echocardiography means that an echocardiography is made before and during different stages up to peak exercise in order to identify wall motion abnormalities. | # Exercise echocardiography means that an echocardiography is made before and during different stages up to peak exercise in order to identify wall motion abnormalities. <Cite>REFNAME12</Cite> An alternative is pharmacological stress testing using dobutamine. | ||
# Myocardium Perfusion Scintigraphy (MPS) is able to show the perfusion of the heart during exercise and at rest based on radiopharmaceutical tracer uptake . | # Myocardium Perfusion Scintigraphy (MPS) is able to show the perfusion of the heart during exercise and at rest based on radiopharmaceutical tracer uptake . <Cite>REFNAME13</Cite> | ||
# Magnetic Resonance Imaging can be done with vasodilatory adenosine or stimulating dobutamine to detect wall motion abnormalities induced by ischemia during pharmacological stress. | # Magnetic Resonance Imaging can be done with vasodilatory adenosine or stimulating dobutamine to detect wall motion abnormalities induced by ischemia during pharmacological stress. <Cite>REFNAME14</Cite> | ||
The findings on stress testing can be used to determine the choice between medical therapy only or medical therapy and invasive assessment of the coronary anatomy in patients with stable angina. Coronary angiography is recommended based upon the severity of symptoms, likelihood of ischemic disease, and risk of the patient for subsequent mortality based on stable angina pectoris risk scores. | The findings on stress testing can be used to determine the choice between medical therapy only or medical therapy and invasive assessment of the coronary anatomy in patients with stable angina. Coronary angiography is recommended based upon the severity of symptoms, likelihood of ischemic disease, and risk of the patient for subsequent mortality based on stable angina pectoris risk scores. <Cite>REFNAME15</Cite> For the algorithm for the initial evaluation of patients with clinical symptoms of angina (Figure 1). | ||
== Coronary Angiography (CAG) == | == Coronary Angiography (CAG) == | ||
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== Treatment == | == Treatment == | ||
Stable angina pectoris can be treated by revascularization (PCI or CABG) or optimal medical therapy. The choice depends on factors such as the severity of symptoms and anatomical complexity of the lesion. Current guidelines for myocardial revascularization, recommend revascularization in patients with persistent symptoms despite optimal medical therapy. | Stable angina pectoris can be treated by revascularization (PCI or CABG) or optimal medical therapy. The choice depends on factors such as the severity of symptoms and anatomical complexity of the lesion. Current guidelines for myocardial revascularization, recommend revascularization in patients with persistent symptoms despite optimal medical therapy. <Cite>REFNAME16</Cite> Furthermore, revascularization is indicated in case of proven large areas of myocardial ischemia, such as a left main stem stenosis, a proximal LAD stenosis or significant three vessel disease. The choice between PCI and CABG depends on the multitude of factors, and the choice should be made in a team including (interventional) cardiologists and thoracic surgeons. | ||
== Medical Therapy == | == Medical Therapy == | ||
Initial treatment of stable angina pectoris focuses on medication to keep the oxygen demand of the heart as low as possible. β blockers lower heart rate and blood pressure, decreasing the oxygen demand of the heart. | Initial treatment of stable angina pectoris focuses on medication to keep the oxygen demand of the heart as low as possible. β blockers lower heart rate and blood pressure, decreasing the oxygen demand of the heart. <Cite>REFNAME17</Cite> Nitrates dilatate the coronary arteries so the heart receives more oxygenated blood. <Cite>REFNAME18</Cite> Antiplatelet therapy (aspirin) reduces the risk of development of a thrombus and thus subsequent (coronary) ischemic events. <Cite>REFNAME19</Cite> | ||
Apart from starting medication the patient needs to minimize/control any present risk factors like smoking, overweight and drinking alcohol. See chronic coronary diseases. | Apart from starting medication the patient needs to minimize/control any present risk factors like smoking, overweight and drinking alcohol. See chronic coronary diseases. | ||
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There are circumstances in which CABG should be considered, including left main or proximal LAD stenosis or multiple vessel disease. The choice for PCI or CABG depends on multiple patient and lesion characteristics and should be discussed in a specialized heart team involving cardiologists and cardiothoracic surgeons. | There are circumstances in which CABG should be considered, including left main or proximal LAD stenosis or multiple vessel disease. The choice for PCI or CABG depends on multiple patient and lesion characteristics and should be discussed in a specialized heart team involving cardiologists and cardiothoracic surgeons. | ||
With CABG, a bypass is placed around the stenosis using the internal thoracic arteries or the saphenous veins from the legs. The bypass originates proximal from the stenosis and terminates distally from the stenosis. | With CABG, a bypass is placed around the stenosis using the internal thoracic arteries or the saphenous veins from the legs. The bypass originates proximal from the stenosis and terminates distally from the stenosis. | ||
== References == | |||
<biblio> | |||
#REFNAME1 pmid = 11756201 | |||
#REFNAME2 pmid = 4997794 | |||
#REFNAME3 pmid = 10099685 | |||
#REFNAME4 pmid = 10866870 | |||
#REFNAME5 pmid = 10751787 | |||
#REFNAME6 pmid = 6831781 | |||
#REFNAME7 pmid = 3925741 | |||
#REFNAME8 pmid = 14678917 | |||
#REFNAME9 pmid = 15289388 | |||
#REFNAME10 pmid = 8375424 | |||
#REFNAME11 pmid = 17162834 | |||
#REFNAME12 pmid = 1352191 | |||
#REFNAME13 pmid = 2007701 | |||
#REFNAME14 pmid = 12566362 | |||
#REFNAME15 pmid = 18061078 | |||
#REFNAME16 pmid = 20802248 | |||
#REFNAME17 pmid = 16735367 | |||
#REFNAME18 pmid = 3925741 | |||
#REFNAME19 pmid = 9355934 | |||
</biblio> | |||